Friday, March 22, 2013

Bullet Point Ethics as Policy Advice?

Bioethics as well as various specialties within the field (research ethics and public health ethics among them) is more often than not policy oriented. This is not terribly surprising, seeing that sound ethics aims at providing action guidance as well as action justification. It remains, of course, a bone of contention among ethicists and philosophers whether this can actually be achieved in the absence of final answers to fundamental meta-ethical questions. Let us leave this thorny issue aside for the moment.  A consensus seems to exist at least among bioethicists and others engaged in applied ethics that we can and should press ahead regardless of those intractable final answers and that we should utilize the tools of ethical analysis to address real-world problems.

Ever since Tom Beauchamp and James Childress hugely successful Principles of Biomedical Ethics entered the textbook market place principles have become a popular teaching tool in many a medical school. Among philosophers these principles have not been as successful as they are among teachers in medical schools, mostly because of concerns about their lack of action guidance and action justification.  Debates among bioethicists about the viability of the Georgetown Mantra will undoubtedly continue, and these debates certainly are to be welcomed. If nothing else, they have already led to marked improvements to the Principles of Biomedical Ethics through its various editions.

However, in the aftermath of the Principles ever more policy guidance documents disguised as ethics guidelines have entered the market place. While I have not undertaken a proper survey of all of these documents, it is my impression that they are particularly prevalent in public health ethics. What is disconcerting about these documents is that they have taken the Principles approach to a whole new level of arbitrariness. Arbitrariness in the sense that while they aim to assist policy-makers in developing action plans for anything from SARS to clinical research to obesity they actually permit arbitrary actions. Vacuous criteria are abound in this new enterprise. A quick search of the literature offers anything from respect for ‘human dignity’ to special attention that must be paid to never clearly explicated ‘vulnerable’ people. Conceptual ethical frameworks are replaced by bullet point lists of the pleasant-sounding. Take all the pleasant-sounding somehow into consideration and you will reach an ethically defensible end-point, or at least an end-point that will give you another shot at high office when the next elections come around.

To be fair, there are a few good reasons for these bullet point lists. Policy makers must take into account the plurality of normative views held in the societies they represent, hence a straightforward consequentialist, deontological or virtue ethical approach would not persuade many. It is also worth noting that many professionals who are not ethicists tend to like bullet point style principles. They use them as guiding lights (deontic constraints, name it) in their search for an ethically defensible answer.

However, considering that these sorts of bullet point lists are frequently supposed to function as an ethical backstop in times of, for instance public health emergencies, it seems unacceptable - to me at least - that they can be used to justify any and no action at all.  Given that their strong selling point is that they are more practical, and that they can be easier operationalized and used by professionals hailing from other disciplines, I cannot help but wonder why there is no evidence that they work better in terms of providing action guidance and action justification than old-fashioned ethical analysis in times of crisis or indeed in preparation for a public health crisis.

Should we not aim higher than this lamentable status quo?

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